Provider Demographics
NPI:1154199115
Name:BROWN, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NORTHGATE DR S
Mailing Address - Street 2:
Mailing Address - City:SATSUMA
Mailing Address - State:AL
Mailing Address - Zip Code:36572-2130
Mailing Address - Country:US
Mailing Address - Phone:551-271-7486
Mailing Address - Fax:
Practice Address - Street 1:110 NORTHGATE DR S
Practice Address - Street 2:
Practice Address - City:SATSUMA
Practice Address - State:AL
Practice Address - Zip Code:36572-2130
Practice Address - Country:US
Practice Address - Phone:551-271-7486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities